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HomeMy WebLinkAbout006-1004-50-000 i Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Lab:rr'andoHuman Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Pwimer's~EL ❑ City ❑ Village Town of State Plan o.: 1NV r CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet t!-I A7 Verit TANKTO P/L WELL BLDG" Airito ntake ROAD Dt Inlet Ar Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe (f,$v Holding Bot. System S'K PUMP/ SIPHON INFORMATION Final Grade Z_ v Manufacturer Demand Model Number GPM I Loss Friction Syetem TDH Ft TDH Lift Forcemain Length Dia. HH Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/ Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Includ code discrepancies, er n resent etc) _ 00~-100-3-`f6-dad ~ ~~C SE a3 LOCATION: Cylon.2.31.16r, NE, SE, 250th St eet_ + d Plan revision required? ❑ Yes ❑ No t Use other side for additional information. i P I I SBD-6710 (R 05/91) Date Inspector's Signature Cert. No Safety and Buildings Division ~~■r■r■ SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less Count than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number The information ou rovide ma be used b other overnment a enc ro rams ,;2 y p y y g g y p g ❑ Check if revi sion to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I',,D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Propert y O er Na Property Location N F1A 5 F114, S o2- T , N, R// E (or)© Property Ovvrler's Mailing Address Lot Number Block Number Cit , State Zip Code Phone Number Subdivision Na a or CSM Number (7i > - 0: aX _/tt, - t5~ X3 7 t st Roa YPE OF BUI DING: (check one) ❑ State Owned C 4e 3 G E] Public 1 or 2 Family Dwelling - No. of bedrooms Village Town of ~ / . 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number s) 0 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home ecrea Iona acl ity 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel / Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1- New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. E] Repair of an -----System System _______System _____________Tank Only - ___Existing System Existi _ B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 'Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6- System Elev. 7. Final Grade Required sq. ft Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation ~J © /U Feet Feet 01J r VII. TANK Capacity gallons Total # of ; Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer s Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank ❑ El ❑ 1:1 1:1 Lift Pump Tank /Siphon Chamber z" ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumb 's Signa ure: (No StaM.05) NMP/MPRSW No.: Business Phone Number: ® 7 4s 7/~45;"' Plu er's Add ss (Street, City, State, Zip CodeA~ 0 IX. COUNTY/ DEPARTMENT USE ONLY E] Disapproved Sapytary Permit Fee (includes Groundwater at A roved surcharge lee) pp ❑ Owner Given Initial Adverse Determination a X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber i INSTRUCTIONS r 1. A sanitary permit is valid for two (2) years. I 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit: issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system Check appropriate box depending on system type. VL Absorption system information. Provide all information requested for numbers 1 through VII. Tank informafion_ Fill in the capacity of every new/or existing tank, list the total gallons, numb+rr of tanks and manuft ct., er's name, indicate prefab or site constructed and tank materia's Cernplete f)- a/! septic, dump/siphon and holding tanks for this system. Check experimental approval only if tanks receives; experimental product approval from DILHR. VIII- Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. m~_)iete puns and specifications not smaller than 8 10 x 11 inches must be suI' i- 'ed to '"?e •.-Unty The plans must Irxt~ the following: A) plotpian, drawn to scale (Yr with complete dimensions, locati<ii;i f Jinci tank(s), septic )l hey treatment tanks; building sewers; wells; water inainslwat(-r set !ce, strc;: :i lak,~ s; pump or siphon hoxet,, soil absorption systems; replacement sySIH arc;a>, and the the building served; nd vert cal elevation reference points;; C) cor•)plete sped f c,rtio . for pur-ip, a, ii c ont-ols- dose volume; c v r~ r ences; friction loss, pump performance curve; pump model and r,urT!p M,:'1 1fa(;urer D) cross section of s , L)sorption system if required by the county; soil test data on a 1 15 ~orin, ar:-;; l) . sizir~~g information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated-prac ices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. . r. ~ Y ~ f of 9~ o to tw~ ° y ♦ M R Aq~T r Y e r I b ~ t I + ~r ` a Z ¢ , I.A ~~I r i 6 ~y i 1 I'I r I ~ Y ' ~ I .:.P `I ' , a r } ix(. i i , i ~ i i~ ~~?r ~ i i i, ~~E i., _ ~ f. i ~ •G j,, 9 k , ~ ~ I ~ { ~ C i ' ~ r e". I I 1 i 1 ` F y E~ I - ~ 1 ~ ~I. ~ t ' ~ i~ - ' k 1.- f. I ' ' ' 4 t.~'. ' ' f. _ f a, ~ r Wisccg in Department of Industry, ND SITE EVALUATION REPORT Page of Labor and Human Relations Divisionbf Safety Buildings Wis. Adm. Code COUNTY Attach complet e site plan on paper not less thain zt include, but not limited to vertical and horizontal reference p% of s ale or PARCEL I.D. # dimensioned, north arrow, and location and dist ~y/~~ IEWED BY DATE APPLICANT INFORMATION-PLEASE PR rMf TION PROPERTY OWNER: PR LOCATION i l w. G T ,&r 1/4 $41~" 1/4,S,2 T N,R f G E (or (q PROPERTY OWNER':S MAILING ADDRESS IC& BLOCK # SUED. NAME OR CSM # CITY, STATE CgqDE PHONE N CITY VILLAGE (TOWN NEAREST.#OAD [d] New Construction Use Residential / Number of bedrooms 3 [ ] Addition to existing building - I ] Replacement [ ] Public or commercial describe Code derived daily flow Sd gpd Recommended design loading rate o .7 bed, gpd/ft2 • trench, gpd/ft2 Absorption area required bed, ft2 -J% trench, ft2 Maximum design loading rate a 7 bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) T.0 ft (as referred to site plan benchmark) ? Additional design / site" considerations Parent material 6 Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem a S ❑ U ERS ❑ U @!~S ❑ U ❑ S 4KU ❑ S Z ❑ S f9 U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bax>dary Roots Bed Trench 1,7 go" Ground 5=31 r/1~3~'y i /n G S 7 , ele . OWL- X Depth to limiting fa )r ~~t• 33 Remarks: " .Qs+*s r •/f - Boring # ~ni4vi<:.14Kh4x;; ~ ^ f0 V / ^ I.+~/I ~~l he%\ C~lY , ~ 9 54 lfsox Is -leg *2, sYf1 z rho r Ground elev. loa.3 ft. Depth to limiting facf; ir, Remarks: CST Name:-PleaL)A"n i.s Q'_: Phone:,~~s ~7Lg . G G 3 7 0~ / Address: 3-7;Z jy0 'rO S7- J¢/frer W s C4 Signature ✓0""r'{ ~tg' g ~,r CST I PROPERTY OWNER SOIL DESCRIPTION REPORT Page!!~-,qf~ PARCEL I.D. # Depth Dominant Color Mottles Texture Structure Consistence Bouncl@ry Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends ?.\i r }aa -54 PAS" InvAlk S Ground '~l~ ~jQ 3/ elev Depth to limiting fac7 oh Remarks: Boring # Q~S ;2m 6v 31 v "s ct .5L ~sfz.- , 7 g Ground L J elev. -7 /OY•SS"ft. Depth to limiting factor Remarks: Boring # kY;44\::-::•:ti: :i l D~ S, K.V. / Arsx \ 9 Ground elev. /oa.3S ft. Depth to limiting fac 7 r, I I I - I I LL] Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) J S.2 T3 N RIG [c/ CSTin 3 Sio 9 Sys? 98, o a~ `n Tai ~ ~/o a, ,cuR,~'• ~ ,~.~.c o~ /a~.•c /mo AA~ ~ sr ~r ~ t f 37~ 3s' H3 >zS jg ~ ,s~ 1 T 1 ~ 1~'7' STC- 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERMUYER ca'4 s T MAILING ADDRESS .2,3 7 y ,2 &-o r! PROPERTY ADDRESS ~?,Q'l 2S-0 S7_ (location of septic system) Please obtain from the Planning Dept. CITY/STATE G~QiL GL'I S- -4%o0 7 PROPERTY LOCATION 1/4, -SAC- 1/4, Section 2 T ~ N-R~W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION LOT NUM13ER CERTIFIED SURVEY MAI'`~~/S3~r~1 , VOLUMEW7, PAGE 41-, LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement, that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner i and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. UWe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR- Certification stating that your septic has been maintained must be completed and returned to the St Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: r DATE: St. Croix COUnty Zoning Office Government Center 1101 Carmichael Road Iiudson. \VI 54016 11/93 S T C - 100 This 'application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/ contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property Location of property JILT 1/4_1/4, Section Z , T 3 / N-R W To shiMailing address Q 3 j ,2S-0'~ S T Address of site Sctm.t u_ Subdivision name Lot no. Other homes on property? Yes No Previous owner of property Total size of property J) y / Total size of parcel 71 Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes k No Volume 9Y7 and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. -'M J O , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the ! construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. ~l9~s3s~ Signature of Applicant Co-Applicant`) r Date of Signature Date o Signature DOCUMENT "IO. i~,L 987PAU 421 THIS SPACE RESERVED FOR RECORDING DATA NARRANTY DEED 493350 STATE BAR OF WISCONSIN FORM 2 - 1982 REGISTER'S OFFICE Robart Yar ardi ST. CRW CO.. WI Recd for Record now DEC 2971,992 .1992 conveys and warrants to x3.~.~3.D ~'~1Mce- a siaale version at 10:20 A J 4 RETURN TO the following described real estate in St - Croix Cc ;nty, State of Wisconsin: ooh 1003 40 Al Of S3 and 53 of 113 of Section t, Township 31 21-, Tax Parcel No: 006 3 Q04 KA Range 16 W.. St. Croix Corxty, WI "RA F~ This 1-0 20t homestead property. *4 (is not) Exception to warranties: some Z 0 this 28th day of - Deeeinber .19 92 7 L) (SEAL) • Robert Mar uaxdt (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGEMENT Signature(s) STATE OF WISCONSIN POLK County. Ss. Personally came before me this 28th day of authenticated this day of , 19 December 19 92 the above named Robert !%"Aardt. TITLE: MEMBER STATE BAR OF WISCONSIN (It not, to me k ir~f`pgr who executed the authorized by § 706.06, Wis. Slats.) foregoing i ge the same. THIS INSTRUMENT WAS DRAFTED BY IRiehael J. Schataon I Keller ve. 3ehaxox Amery. WI 54001 Not Pb POLK County, Wis. (Signatures may be authenticated or acknowledged. Both MY o' ►i" (It riot, statexpiration are not necessary.) date % 19 ) • Names of persons signing in any capacity should be typed or printed below Ow sgwailures. F '1 WARRANTY DEED STATE BAR OF WISCONSIN WISCONSIN REAI.TORS/ ASSOCIATION FORM No. 2 - 1982 4801 Hayes Road, Madison, W iisconsin 53704 I i , I I I I , L I i I I I I; , I w , i I C.\OSaT C\osE-c i ~ I I , I 4 I i i P `{yf~,^1 1 ~'qfI l~1 7 4 t 9 1 j i II a c 0 i r J r t P k I 09, IR Mi NrR1iIfNVMM'M~N.'.iwi~uNMw~M"'w+. ' ~ H ~ I y 1 t ~ ~ \ /t i i 3 S U~ ~ ~r ~ 2 d s